“It felt great when I saw myself”: Our Health Matters Report on Gender-Affirming Health Care for Transmasculine People
Authors: Heather Santos, Venkatesan Chakrapani, Madhusudana Battala, Shaman Gupta, Aditya Batavia, Ayden Scheim
Our Health Matters
Our Health Matters is a community-based participatory research study of trans men’s and transmasculine people’s health in India. The study uses qualitative (in-depth interviews) and quantitative (survey) methods to explore and bring attention to transmasculine people’s experiences in society and how they impact health and well-being. This report focuses on data from the qualitative phase of the research.
The project is led by a Steering Committee of transmasculine community members and a team of trans and non-trans researchers from Drexel University (Philadelphia, USA), the Population Council (New Delhi), and other organizations in India, Canada, and the USA. Project partners include TWEET Foundation and Transmen Collective. Click here for more information about the study team.
Many transgender and non-binary people need gender-affirming (or transition-related) care, including hormone therapy and surgery. Access to gender-affirming care has been associated with improved mental health among trans and non-binary individuals, such as reduced depression and anxiety. Studies also indicate that hormone therapy can positively impact quality of life. However, trans and non-binary people face many barriers to such care, including limited information, costs and lack of
insurance coverage, discrimination from medical staff, and a lack of doctors who are knowledgeable about gender-affirming care.
Despite legal recognition of trans people’s rights to gender self-identification and health care in India, the community continues to face barriers to gender-affirming and general health care. A recent review of 67 studies on access to health care for trans people in India identified common barriers including stigma and discrimination, limited access to free or low-cost care, and lack of treatment protocols. None of the studies focused on health care for the transmasculine community. More broadly, a review conducted by members of our team found limited published research on transmasculine people’s health in India and globally. To help fill this gap, this report focuses on experiences accessing gender-affirming care among trans men and transmasculine people in India.
Whom did we speak to?
We spoke to 40 transmasculine people who ranged in age from 20-50 (average = 28) and lived in 10 states in India. Participants self-identified with varied caste, religious, and socio-economic backgrounds.
How did we collect and analyze our data?
Forty in-depth interviews were conducted in Hindi or Marathi by peer researchers (trans men) via telephone or video conference in July and August 2021. The interviews were audio-recorded, transcribed, and then translated. A semi-structured interview guide was used. It focused on family experiences, social and community support, experiences of discrimination and safety, and access to health care. The questions about health care focused primarily on transition-related care. The interview transcripts were analyzed by four team members with previous experience in conducting qualitative data analysis, with the involvement of Steering Committee members.
What did we find?
The experience of trans men and transmasculine participants trying to access gender-affirming care usually began with a search for potential doctors, largely through their peers. They then had to weigh the affordability and quality of the limited number of available services, and navigate the approval process for gender-affirming care, which usually involved seeking a letter or two from a psychiatrist or psychologist. Along the way, participants had a range of both negative and positive experiences with
doctors, nurses, pharmacists, and other health care providers. Finally, despite these challenges, participants who had achieved their transition-related goals described positive impacts on their health and well-being.
Weighing the affordability of services
Weighing the quality of services
Overcoming diagnostic barriers
Achieving transition goals
|General Health Care |
As with gender-affirming care, participants had a range of negative and positive experiences when seeking general health care. Negative experiences with general physicians included unnecessary invasive examinations, being refused care, and hesitancy to disclose their gender identity. In contrast, some participants noted positive reactions after they explained their trans identity.
“Once I went to a doctor because I had a back problem. At that time, he did an X-ray examination. At that time, I told him that I had a transition and an operation. I told them the details. He then examined me physically without my permission, and he also examined my private parts, which was not necessary.” (24, Pune)
“Because my name was a female name and my appearance was as a boy. So, I explained to him about myself, and he reacted positively. He said I knew there was something different. My experience with that doctor was very good.” (30, Delhi)
Conclusion and Recommendations
Our Health Matters participants often faced barriers to gender-affirming health care, including a lack of publicly accessible information, costly or low-quality care, discrimination, and excessive screening processes before providing the “GID” certificate. However, we also heard about how transmasculine people supported each other to find suitable doctors, and how they were persistent in overcoming obstacles to hormones and surgery.
Based on our findings, we recommend the following changes to minimize the challenges faced by transmasculine persons accessing gender-affirming health care in India. These actions can be taken by central government ministries (e.g., Ministry of Social Justice and Empowerment, National Health Authority), state governments, international organizations (e.g., United Nations Development Programme), medical associations, and trans networks.
Improving Access to Information
- Publish multilingual information about trans-affirming and transition health care, including a database of providers (e.g., online databases managed by community-based organizations or government agencies in different states of India).
- Provide funding to community-based organizations to strengthen and formalize existing referral and support networks.
Increasing Affordability and Quality of Care
- Increase coverage of transgender health in medical curricula. See the TransCare: Med-Ed project for additional information.
- Offer training on trans-affirming care for existing medical staff.
- Fully implement the recently-announced initiatives (i.e., through the Ayushman Bharat scheme) to increase access to gender-affirming care through public hospitals, while addressing barriers for transmasculine people who do not want an ID card that labels them as transgender, or who face challenges trying to apply for one.
- Increase skills-building training opportunities for doctors who may prescribe hormones for transmasculine patients, as well as surgeons who may perform gender-affirming surgeries, particularly those who will be listed under the Ayushman Bharat scheme .
- Develop trans-affirmative clinics for hormone prescriptions and injections (e.g., drop-in sessions with medical staff at community organizations and government hospitals). It may also be helpful to offer other health care services at these clinics (e.g., sexual and reproductive care).
Overcoming Diagnostic Barriers
- Revise clinical guidelines and practices to follow the 8th edition of the World Professional Association for Transgender Health Standards of Care, which focus on the patient’s ability to give informed consent, rather than on diagnosing gender dysphoria. If a referral letter (e.g., from a psychiatrist) is needed, only one such assessment should be required. Further, the placement of ‘Gender incongruence’ in the Sexual Health chapter of WHO’s International Classification of Diseases-11th edition (ICD-11) seems to indicate that diagnosis of ‘Gender incongruence’ need not necessarily be made by psychiatrists.
- Improved communication between medical organizations, doctors, and community members to prevent patients from pursuing multiple assessments or other services that are not needed.
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